A Refractory Case of Syphilis-Induced Longitudinally Extensive Transverse Myelitis: A Case Report

Case Diagnosis: A 29-year-old male with refractory transverse myelitis (TM) in the context of neurosyphilis.

Case Description or Program Description: A 29-year-old previously healthy male presented with sudden-onset imbalance, requiring a cane for ambulation. Magnetic resonance imaging (MRI) revealed hyperintensity from C7 to T11, consistent with TM. He improved with intravenous (IV) methylprednisolone (1 g/day for five days) and was transferred to an acute rehabilitation unit, ambulating with a walker. He worsened one day post-discharge and was readmitted. Serologic testing confirmed syphilis (positive rapid plasma reagin and Treponema pallidum antibody), leading to a diagnosis of syphilitic TM. He was treated with 14-days of IV penicillin G, but spinal MRI showed lesion progression (C3 to T11), prompting initiation of plasma exchange therapy (PLEX). Persistent deficits prompted a five-day IV immunoglobulin (IVIG) course (0.4 mg/kg), improving ambulation. He deteriorated again two days later, requiring another five-day IV methylprednisolone course. Post-treatment MRI showed persistent hyperintensity (T2 to T9), and he struggled to regain independent ambulation.

Setting: Tertiary care hospital and rehabilitation center.

Assessment/Results: Despite aggressive treatment, the patient exhibited recurrent exacerbations with limited sustained improvement, as serial MRIs showed persistent spinal cord hyperintensity correlating with functional decline. His transient IVIG response suggests an autoimmune component, while rapid post-steroid decline raises concerns about immune modulation.

Discussion (relevance): This patient's fluctuating deficits requiring adjustments in therapy highlights the complex interaction of infectious and immune mechanisms in syphilitic TM and emphasizes the challenges of restoring function in treatment-resistant TM. Given the rarity of syphilitic TM, treatment strategies are often extrapolated from other myelitis forms, highlighting the need for further research into neurorehabilitation approaches and reinforcing the importance of multidisciplinary rehabilitation in refractory cases.

Conclusions: Functional recovery in progressive TM is challenging, requiring serial assessments to guide therapy. While antimicrobial therapy remains standard, persistent deficits may need early, aggressive and individualized rehabilitation tailored to neurological recovery.